The surgical treatment of portal hypertension is a long debated topic, and all surgical approaches have attempted to address its fatal ruptured esophageal and fundic varices in different ways. In 1963, Starzl performed the world’s first liver transplantation, which brought a ray of hope for its surgical treatment. Liver transplantation is the ultimate treatment Liver transplantation is the only cure for end-stage liver disease and has been widely used internationally in the treatment of portal hypertension in cirrhosis in recent years as a direct means of attacking the cause of the disease, revolutionizing its treatment in a way that is unmatched by traditional shunt and flow disconnection surgery. Currently, there is a consensus to perform liver transplantation in patients with Child C. Specific indications include: 1) repeated upper gastrointestinal bleeding, which is ineffective with medical, surgical and interventional treatment; 2) uncorrectable coagulation dysfunction; 3) hepatic encephalopathy; 4) intractable ascites. The contraindications are pulmonary hypertension (pulmonary artery pressure >35 mmHg) and severe infections, and it is still controversial whether and when liver transplantation is indicated for patients with Child A and B upper gastrointestinal bleeding. If liver transplantation is performed early in the course of the disease, although the surgical success rate is high, liver transplantation is an invasive and risky procedure with insurmountable complications such as biliary ischemia and the need for lifelong postoperative immunosuppression, making it difficult to be preferred by physicians, patients and families. Ultimately, it should be considered based on the patient’s specific condition, the effectiveness of other methods of treatment, the experience of different medical centers and donor allocation. Although the 21st century has been called the “age of transplantation”, this does not mean that liver transplantation can fully replace traditional bypass and dissection surgery in the treatment of portal hypertension today. The shortage of donors and the high cost of treatment have limited the development of liver transplantation to a considerable extent, so that shunt and dissection surgery will continue to dominate the treatment of portal hypertension for a long period of time. As early as the 1950s, Linton concluded that the prognosis of patients with portal hypertension depends mainly on the status of liver function and has little to do with the surgical procedure. 50 years later, we have a better understanding of this. The bypass and dissection procedures have no therapeutic effect on the primary liver disease, which will continue to progress after surgery; they also impair liver function to varying degrees and may further accelerate the progression of the primary liver disease. Because of this, the difference in efficacy between the different conventional procedures is only in the rate of control of bleeding from ruptured varices, and no significant improvement in survival is possible. Therefore, liver transplantation is the ultimate treatment for portal hypertension. In this regard, individualized protocols based on the reserve function of the liver are the key to treatment.